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Applications Will Be Proct , When Submitted Properly Completed. Be Sure gn The Application.
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<br />APPLICATION
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<br />(For Non -Transferable, Revocable; and Suspendable) _ SEPTAGE
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<br />ENVIRONMENTAL HEALTH•PERMIT
<br />JFE.P �1
<br />UQUID WASTE
<br />EXPLANATION
<br />Application IS reb made car on tMine-ss In ttheArisdictional area of the n oa In Local %ealt Otrict
<br />REMITTANCE $
<br />h Business Name (08A) +moi, rXifi4!�. AddresSQ/ "'
<br />CHECKED
<br />Owner Address — - -
<br />--
<br />Firm Partners, Addresses and Telepho a Numbers
<br />PATE
<br />3. Business Telephone No. Emergency Telephone No.
<br />Plant Location
<br />Contractor Licence No.
<br />No. Units Served
<br />Plant Capacity _ _; ... ., _. -.
<br />_
<br />7. 11 LAUNDRY For July 1, =June 30, 19 ^--- f -.
<br />Applicants Name (Print)Title Date
<br />SIZE: C1 Less Than 1,000 Sq. Ft., 11 More Than 1',000 Sq, F -.--_ t. I '� -. r - --
<br />Please check Applicable Category (1-7) and Fill in the Required Information
<br />❑ DRY CLEANING'. Chemicals U9ed/Amount/M�.
<br />1. ❑ PUMPER VEHICLE PERMIT REGISTRATION FOR EACH VEHICLE)
<br />For July 1,'- - • ' • June 30, 19 • Disposal Sites - _
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<br />1 .0_ a'>
<br />Description (Make/Yr., Color) '
<br />LESS
<br />Serial No. CAL. License No. CAL. License Renewal No.
<br />f hereby.certi have prepared this application and that the work will be done in accordance with
<br />Capacity Gal., Weights & Measures No.
<br />lthat,l
<br />i5rdinedces-et t0 la*i, and rule d regulation of the S quln L c Health District.
<br />Equipment Parking Address
<br />APPLICANT'S SIGNATUREXi','`
<br />PRORATION
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<br />2. ❑ PUMPER YARD
<br />For July 1, * June 30, 19
<br />No. Vehicles Stored
<br />of
<br />No. of Chemical Toilets Stored
<br />3. ❑ PERCOLATION TEST
<br />R.S. or R.C.E. Name R.S. or R.C.E. No.
<br />Teocation Test Date/Time
<br />4. � SANITATION PERMIT
<br />Job Address/ oc tion �
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<br />Owner EV90 , 7�TrT- Address 1 z
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<br />❑SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑PACKAGE PLANT
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<br />11 PERMANENT ` 1-1TEMPORARY - C]NEW REPAIR J40THER jP0F.#/4J
<br />JFE.P �1
<br />S. ❑ CHEMICAL TOILkTS F,or+July 1, - June 30, 19
<br />EXPLANATION
<br />Type Construction t Disposal Site <
<br />REMITTANCE $
<br />No. of Units ' ' Equipment Storage/Cleaning Location(s) 1
<br />CHECKED
<br />S. ❑ PACKAGE,TREATMENT.PLANT. For July,1, - Juni,36'`19
<br />Operator Name t - Where Certified
<br />PATE
<br />-DATE REMITtEU
<br />Plant Location
<br />w,, .�„
<br />I 4 1
<br />No. Units Served
<br />Plant Capacity _ _; ... ., _. -.
<br />7. 11 LAUNDRY For July 1, =June 30, 19 ^--- f -.
<br />SIZE: C1 Less Than 1,000 Sq. Ft., 11 More Than 1',000 Sq, F -.--_ t. I '� -. r - --
<br />t�
<br />❑ DRY CLEANING'. Chemicals U9ed/Amount/M�.
<br />FEE `
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<br />r' t 11
<br />1 .0_ a'>
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<br />LESS
<br />f hereby.certi have prepared this application and that the work will be done in accordance with
<br />San Joaquin County
<br />lthat,l
<br />i5rdinedces-et t0 la*i, and rule d regulation of the S quln L c Health District.
<br />APPLICANT'S SIGNATUREXi','`
<br />PRORATION
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<br />FOR DEPARTMENT USE ONLY
<br />r-, ri ..,.r rn 171 n f'1 2--. , A Ra lve l Rv Januasv 31
<br />0 July 1 & Reteind By July 31
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<br />REMIT
<br />BASE
<br />EXPLANATION
<br />BILLING
<br />REMITTANCE $
<br />AMOUNT OUE
<br />CHECKED
<br />PATE
<br />-DATE REMITtEU
<br />AMOUNT
<br />FEE `
<br />rI
<br />r' t 11
<br />1 .0_ a'>
<br />-
<br />LESS
<br />,
<br />PRORATION
<br />PEN LTY
<br />OTHER
<br />OTHER
<br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E. HAZELTON AVE., P.O. ox 2009 •STOCKTON, CA 95201
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